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d*( t2a6.6() <br /> Sanitary Permit Application Safety&Buildings Di <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington <br /> See reverse side for instructions for completing this application <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI5 77 <br /> isox <br /> eonsin <br /> 07 <br /> LPrivacy Law,s. 15.04(1)(m)] (Submit completed form to countyt <br /> County <br /> Attach com lee tans to the county copy on] )for the s stem, a cr not les than 8-1/2 x 11 inches in size, state o d <br /> State Sanitary Permit Number ❑C k if re 'si o prions applica' n State Plan L D.Number <br /> I.App ication Information.-Please Print all Information 7f <br /> Property Owner Name Location: <br /> Property Location <br /> roPertY Owne s a'pnrAddress 1/4 I/4,S2t7 ,N,R o <br /> Lot umber Block Number <br /> City, tate Zip Code <br /> ` -� Phone Number Subdivision Name or CSM Number <br /> II. ype of Building: (check ones)) 6-9 331 - d$� <br /> 1 or 2 Family Dwelling-No.of Bedrooms: Z ( 'C� ❑City <br /> ❑ Public/Commercial(describe use): ❑Village <br /> ❑ State-Owned ''own of <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) iiv <br /> 1/ <br /> A) L ANew.System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition toS stem Tank Onl Existin S stemB) eernitNumber❑A Sanita Permit was reviousl issued <br /> IV,Type of POWT System: (Check all that apply) <br /> XNon-pressurized In-ground ❑Mound <br /> ❑Pressurized In-ground ❑Sand Filter ❑Constructed Wetland <br /> ❑At-,grade ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> ❑Aerobic Treatment Unit 11Recirculatin ❑Other: <br /> V.Dis ersaUTreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Re wired <br /> Proposed� Rate(Gals./da /sQ�R <br /> ) (Min./inch) Elevation <br /> ^ <br /> 95 . 9 S. 1 <br /> VI.Tank Capacity in Total #of Manufacturer <br /> Information Gallons Gallons Tanks Prefab Site Steel Fiber- Plastic <br /> New Existing Con" Can- glass <br /> Tanks Tanks ''pp ,," 1�� trete strutted <br /> �abQ �— /vDESLa ❑ ❑ ❑ ❑ <br /> s <br /> VII. Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. N <br /> Plumber's Name(print) Plumber's Signature(no stamps): <br /> f�Lr��,,��, �' P) IvIP/MPRS No. r Business Phone Number c <br /> umbe�d�(Street,CityStat5 ALL-- <br /> e,Zip Co e) / J' �,�7 i <br /> 2.77(0 <br /> 3s W67t3 W►• .54<, <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit FIncludes groundwater Da 5k�d Z <br /> iWAPPrOVed ❑Owner Given Initial Adverse Surcharge Fe W (// `�//// Issuing A en igna a s) <br /> Determination 00• <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> i <br /> i <br /> v3 .i L1 <br /> SBD-6398 R07/00 <br /> AM 2 2 2002 <br /> i uPj\ ,_... C 0 Iiia T t <br />